Not One Penny More

By Kim Bellard, May 21, 2015

If you've been to a doctor's office or seen some other health care provider, chances are you've had to sign a patient consent form that, among other things, makes you promise that whatever they end up doing to you, and however much they choose to charge you for it, you're responsible for paying.  If your health plan happens to get you a negotiated rate and perhaps covers some of the expenses, that's great, but the provider is still looking to you for payment.

Maybe you shouldn't be so quick to sign.

I don't know which is worse: that providers don't think they should tell you in advance what they plan to do to you, or that they don't want to admit how much they will try to charge for it.  Honestly, why do we keep falling for this?

I thought about this when reading Kaiser Health News' Radical Approach to Huge Hospital Bills: Set Your Own Price.  It profiles benefits consulting company ELAP Services, which goes beyond traditional services like benefits design, direct contracting, and medical bill reviews by also vowing to go to court if necessary to support their customers in disputes over medical bills.

The KHN article cited the example where an employee of one of ELAP's clients had back surgery and was billed $600,000 by the hospital.  ELAP analyzed the hospital's Medicare's cost reports, and advised the client to pay a much lower amount.  "We wrote a check to the hospital for $28,900 and we never heard from them again," said the client's CFO.

ELAP CEO Steve Kelly says "overwhelmingly, the providers just accept the payment."  ELAP has clients write their process for determining reimbursements into benefit plan documents to give greater legal weight.  They already have a federal court ruling in support of their process.  The contract requires them to defend patients from any collections efforts, in return for a percentage of the savings.

Most health plans base their out-of-network payments on "reasonable charges," which is how most health insurance plans worked prior to the advent of network plans like PPOs, when negotiated payment rates became the norm.  

Whether it has worked as intended is not entirely clear, but what is clear is that providers can come after patients for amounts not paid out-of-network by the health plans, all the way up to billed charges, not just to the "reasonable charges."

What I want to know is, if health plans truly believe their limits on charges are reasonable, why don't more of them act like ELAP when providers' charges exceed them?   ELAP makes it clear whose side they are on; health plans, not so much.

I view the charge structure of most providers as a pernicious symptom of much of what is wrong with our health care system.  They rarely have much to do with either actual costs or market forces, and they reflect an arrogant attitude that consumers are there to be gouged as much as possible.  Or, more charitably, if not arrogance, then a certain benign neglect to patients' financial well-being.  

I'd love to see a health plan whose EOBs not only detailed how much they were paying and how much of the remaining balance the consumer had to pay, but also said, "by the way, we think $X is the most your provider should charge you for this service, and we don't think you should pay a penny more.  If they try to charge you more, let us know and we'll help you fight it."

Now that would be a health plan that consumers would think more of, one that is truly on their side.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


Impact of Stress on Health Risk

By Claire Thayer, May 20, 2015

Stress is prevalent, and at some point, all of us are faced with some type of stress in our lives.  What is considered as a stressful situation to one person may be inconsequential to another.  A recent WebMD study finds that 43% of all adults suffer adverse affects from stress. WebMD tells us that a little stress every now and then is not something to be concerned about. However, it’s the ongoing chronic stress that can cause or exacerbate many serious health problems, including:

  • Mental health problems, such as depression, anxiety, and personality disorders
  • Cardiovascular disease, including heart disease, high blood pressure, abnormal heart rhythms, heart attacks, and stroke
  • Obesity and other eating disorders
  • Skin and hair problems, such as acne, psoriasis, and eczema, and permanent hair loss
  • Gastrointestinal problems, such as GERD, gastritis, ulcerative colitis, and irritable colon

MCOL’s infoGraphoid for this week takes a look at the impact of stress on health risk, outlining three different types of stress and the impact on both overall physical and mental health:

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.


Patient Reported Outcomes

By Clive Riddle, May 15, 2015

The National Quality Forum defines Patient-Reported Outcomes (PROs) as "any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else." They elaborate that “in other words, PRO tools measure what patients are able to do and how they feel by asking questions. These tools enable assessment of patient–reported health status for physical, mental, and social well–being.”

The concept is obviously not new, but has certainly been overlooked at times. In an era with tremendous advances and emphasis in patient engagement, mobile health technologies, patient-centered care, we need to continue to see application of PROs receive the attention they deserve.

Dr. Bruce Feinberg, vice president and chief medical officer of Cardinal Health Specialty Solutions, tells us "As our healthcare system moves toward a value-based care model, the role of the patient is becoming increasingly important. We need to reframe the way we think about care to include not only the cost and clinical effectiveness of the treatment, but also the burden of disease and therapy on the patient's perceived sense of well-being. Patient-reported outcomes (PRO) are key to this equation, particularly for patients being treated for high-cost, complex diseases such as cancer or rheumatoid arthritis (RA)."

Dr. Feinberg’s organization is presenting a series of new clinical studies demonstrating the potential role of PRO research in improving the quality and reduce the costs of treatment provided to patients with complex diseases, at the International Society of Pharmacoeconomic and Outcomes Research (ISPOR) annual meeting.

Here's an overview of some of the key findings they will be presenting:

  • One study used PRO to demonstrate that rheumatologists significantly underestimated the negative impact of RA disease burden and treatment on their patients' sense of well-being. Understanding this disparity in perceptions can help physicians make effective treatment decisions that lessen the burden on patients – and can sometimes also reduce the costs of their care.
  • Another study showed that PRO can be critical to identifying and managing medication access and adherence challenges for high-cost specialty drugs.
  • Of a total of 239 oncology and rheumatology patients who were contacted at the time of their initial prescription to provide patient reported outcomes, 28% were identified as having problems that either restricted access or adherence to the drug.
  • Armed with this information, interventions and support services were provided to address those challenges. With the support of these interventions, a medication possession ration exceeding 95% was achieved – enabling nearly all patients to initiate or continue treatment.
  • A third study  proved the feasibility of collecting PRO at the point of care. In the clinical study involving 3,185 RA patients, PRO data was captured during 90% of physician visits. The participating physicians were then able to utilize the data to inform real-time treatment decisions at the point of care.

Annual Global Oncology Medicine Spending Tops $100 Billion

by Clive Riddle, May 7, 2015 

The IMS Institute for Healthcare Informatics has just released a new report:  Developments in Cancer Treatments, Market Dynamics, Patient Access and Value: Global Oncology Trend Report 2015 which tells us “total global spending on oncology medicines – including therapeutic treatments and supportive care – reached the $100 billion threshold in 2014, even as the share of total medicine spending of oncologics increased only modestly.” 

The report found that “growth in global spending on cancer drugs – measured using ex-manufacturer prices and not reflecting off-invoice discounts, rebates or patient access programs – increased at a compound annual growth rate (CAGR) of 6.5 percent on a constant-dollar basis during the past five years. Oncology spending remains concentrated among the U.S. and five largest European countries, which together account for 66 percent of the total market, while the rising prevalence of cancer and greater patient access to treatments in pharmerging nations continues to grow and now accounts for 13 percent of the market” 

Murray Aitken, IMS Health senior vice president and executive director of the IMS Institute for Healthcare Informatics tells us“the increased prevalence of most cancers, earlier treatment initiation, new medicines and improved outcomes are all contributing to the greater demand for oncology therapeutics around the world. Innovative therapeutic classes, combination therapies and the use of biomarkers will change the landscape over the next several years, holding out the promise of substantial improvements in survival with lower toxicity for cancer patients.” 

Findings shared in the report include: 

  • Growth in the U.S. has risen more slowly at 5.3 percent CAGR, reaching $42.4 billion in 2014, representing 11.3 percent of total drug spending compared to 10.7 percent in 2010.
  • in the EU5 countries oncology now represents 14.7 percent of total drug spending, up from 13.3 percent in 2010.
  • Targeted therapies now account for nearly 50 percent of total spending and have been growing at 14.6 percent CAGR since 2009.
  • Within the U.S., two-thirds of Americans diagnosed with cancer now live at least five years, compared to just over half in 1990.
  • The availability of new oncology medicines varies widely across the major developed countries, with patients in Japan, Spain and South Korea having access in 2014 to fewer than half of the new cancer drugs launched globally in the prior five years.
  • Average therapy treatment costs per month have increased 39 percent in the U.S. over the past ten years in inflation-adjusted terms. Over the same period, patient response rates have improved by 42 percent and treatment duration has increased 45 percent, reflecting improved survival rates.
  • Within the U.S., patient out-of-pocket costs have risen sharply for intravenous cancer drugs, increasing 71 percent from 2012 to 2013, reflecting changes in plan designs and increased outpatient facility costs. 

An interactive version of the full report is available via iTunes, but requires am iPad for viewing. Pdf versions of exhibits can be downloaded here


Four Factors Fueling Demand for Telehealth

By Claire Thayer, May 7, 2015

Telehealth, as defined by the Health Resources and Services Administration, is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. 

MCOL’s infoGraphoid for this week identifies these four factors as the key components fueling the increasing demand for telehealth:

  • Reduce Health Care Costs
  • Improve Access to Care
  • More Productive Workforce
  • Better Patient Experience

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.